HospitalInspections.org

Based upon observations and staff interviews on November 3, 2021 between approximately 1000 to 1500 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering.

The findings include:

The main obvious exit from the main lobby to the public way was locked and blocked with stanchions.

NFPA 101 (2012) 19.2.1, 7.1.10.1

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview of November 3, 2021 between 1000 to 1500 hours the facility failed to maintain their laboratories in a safe and fire resistant manner in accordance with the referenced NFPAs. This could lead to the inability of staff or machinery to function as they should in the event of an emergency or exposed chemicals to magnify the effects of a fire and expose patients, staff, and visitors to these fire dangers.

The findings include:

The laboratory fire policy included the use of a fire blanket. Upon staff interview, it was determined that the laboratory had no fire blanket.

NFPA 99 (2012) 15.4, NFPA 45(2011) 6.6.3.2

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on November 3, 2021 between approximately 1000 to 1500 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include:

The last kitchen inspection, testing and maintenance report had the following deficiencies which according to the facility had not been corrected.

Kitchen gas valve did not trip under waterflow conditions
Duct fan did not trip upon activation
Kitchen system piping through hood is not greasetight 1.25 copper piping

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.2.5.1, 9.2.3, 2.1, NFPA 96 (2011 ed) 1.1.1, 10.4.1
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.2.5.1, 9.2.3, 2.1, NFPA 96 (2011 ed) 1.1.1, 8.2.3.1
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.2.5.1, 9.2.3, 2.1, NFPA 96 (2011 ed) 1.1.1, 5.1.4
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility has failed to have their fire alarm system installed in accordance with the references NFPAs and in a manner that is approved. This could result in a fire not being detected by the fire alarm system, possible leading to harm and delayed evacuation of patients, staff, and visitors.

The findings include:

The doctor sleep room in the emergency room did not have smoke detector coverage.

NFPA 101 19.1.3, 6.1.14, 28.3.4.5 (2012)
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The last annual sprinkler inspection report from July 2021 had the following deficiencies which have not been corrected.

The 20 year sprinkler heads in the surgery area were last tested in 2002. They are required to be tested and/or replaced at ten year intervals.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 5.3.1.1.1.3


The five year internal sprinkler inspection was last completed in June 2016.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 14.2.1


The sprinkler dry pipe stand on the roof had a 2.5 inch hose valve that is bad and was not replaced.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 4.1.4.1



The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include:

There were no fire extinguishers observed at the heliport and the facility confirmed that none were present.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010 ed) 1.1, 5.5.5, NFPA 418 (2011) 9.2

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients, staff, and visitors.

The findings include:

The fire/smoke damper report from 2016 showed 6 dampers that failed inspection and the facility could not provide evidence of repairs.

Contractor report must be free of deficiencies.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.2.1, 7.2.1.15.2, NFPA 80 (2010 ed) 1.1, 19.4.9.1.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility failed to properly maintain their elevators.

The findings include:

The facility could not produce records of monthly elevator recall testing for both elevators in the building.

Both elevators in the building have not had annual inspections since June 2020.

Elevator room 3 hour door to conference room A is missing the handle, exposing the door core.

NFPA 101 (2012) 19.5.3, 9.4.6.2

NFPA 101 (2012) 19.5.3, 9.4.2.2

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility has failed to maintain a written plan for the protection of all patients, staff and visitors and for their evacuation in the event of an emergency. At a minimum a written care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

The findings include:

Upon review, the evacuation plan was missing the following sections:

(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(9) Extinguishment of fire

NFPA 101 (2012) 19.7.2.2

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility has failed to prohibit the use of all space heaters in resident areas and non-approved heaters in staff areas. This could result in a fire due to the ignition of combustible materials that would place patients, staff, and/or visitors in danger.

The findings include:

Conference Room C space heater was not approved.
Patient Financial Services space heater not approved.
Education "B" Office space heater not approved.
HIM Office had a space heater plugged into a powerstrip.

NFPA 101 (2012), 19.7.8

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility failed to maintain a maintenance program for their medical gas equipment. This could lead to the equipment malfunctioning endangering patients, staff, and visitors.

The findings include:

The medical gas report dated April 2021 stated that the OR 2 had a hose drop that was recommended to be replaced.

The facility has no records of replacement or repair.

NFPA 99 (2012) 5.1.14.2.2.4

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility did not complete a matrix to determine if their operating rooms were considered wet locations. Operation rooms are by default considered wet locations and require either GFCI or isolated power. This could potentially endanger patients and staff in the operating room if liquids come in contact with the electrical receptacles.

The findings include:

The facility had not conducted a matrix to determine if the ORs were wet.

The facility was unaware that they had LIMs, and had not been testing them.



NFPA 99 (2012) 6.3.2.2.8.4

NFPA 99 (2012) 6.3.4.1.4

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 20201 between approximately 1000 to 1500 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility was unable to produce records of a fuel test conducted within the past 12 months.

The facility stated that the diesel stored for the generator was also being used for boilers and water tanks.

NFPA 99 (2012 ed) 6.4.4.1.1.3, 2.1, NFPA 110 (2010 ed)1.1, 8.3.8, 8.1.1

NFPA 99 (2012 ed) 6.4.1.1.15, 2.1, NFPA 110 (2010 ed)1.1, 5.5.1


The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

The laboratory break room had a water-cooler/heater, Keurig, and refrigerator plugged into one powerstrip.

The Education "B" Office had a refrigerator, coffee maker, and water-cooler/heater plugged into one powerstrip.

The Purchasing Office had a Keurig and refrigerator plugged into one powerstrip.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.5.1.1, 9.1.2, 2.1, NFPA 70 (2011 ed) 90.2 (A), 400.8

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on November 3, 2021 between approximately 1000 to 1500 hours the facility has failed to maintain compressed gas cylinders, which could lead to damage of oxygen storage cylinders, which could endanger patients, staff, and/or visitors.

The findings include:

There was an unsecured oxygen cylinder in the acute care clean room. Fixed at the time of inspection.

NFPA 99 (2012), 11.6.2.3

The above was discussed and acknowledged by the facility staff.